Cardiac Rehabilitation for Vulnerable Populations and Low Socioeconomic Groups: A Systematic Review of Randomized Controlled Trials and Primary Studies

Abstract

Background: Cardiovascular disease (CVD) remains the leading cause of global morbidity and mortality, yet participation in cardiac rehabilitation (CR) is severely inequitable — patients from low socioeconomic status (SES) backgrounds, racial and ethnic minorities, rural communities, and other vulnerable groups remain disproportionately underrepresented despite demonstrated benefit. This systematic review comprehensively evaluates the evidence on CR effectiveness, access barriers, and intervention strategies tailored to vulnerable and low-SES populations across diverse health settings.

Methods: The study strictly adhered to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020 guidelines. Studies eligible for inclusion were randomized controlled trials (RCTs) and primary observational or interventional studies enrolling participants identified as low-SES, socioeconomically vulnerable, racially/ethnically underrepresented, rural-dwelling, or from low- and middle-income countries (LMICs), examining CR or exercise-based rehabilitation interventions and reporting at least one predefined clinical, functional, psychosocial, or behavioural outcome.

Results: Structured interventions combining financial incentives and case management significantly improved CR adherence in low-SES patients (completion ≥30 sessions: 62% vs. 11% usual care; AOR 13.2, 95% CI 4.0–43.5; p<0.001). Technology-based, home-based, and hybrid CR models demonstrated efficacy comparable to traditional center-based CR in reducing cardiovascular events and improving HRQoL in low-resource settings. Telehealth CR enhanced attendance and functional outcomes in rural and underserved populations. Financial disincentives, transportation barriers, low health literacy, and provider implicit bias were identified as the dominant structural barriers to equitable CR access.

Discussion: The synthesis of evidence reveals a persistent and clinically significant CR participation gap in vulnerable populations, mediated by multilevel structural, socioeconomic, and systemic factors. Multifaceted, patient-centred interventions combining financial incentives, case management, telehealth delivery, and culturally tailored content represent the most effective strategies to bridge this gap. Digital health inequity (the 'digital divide') poses an additional barrier that must be addressed alongside clinical CR programme design. Hybrid CR models demonstrate particular promise for LMIC settings where traditional centre-based infrastructure is unavailable.

Conclusion: CR remains underutilized in vulnerable and low-SES populations globally, despite robust evidence of clinical efficacy. Scalable, affordable, and equity-focused CR models combining financial incentives, remote delivery, and targeted case management are urgently required. Future research must prioritize diverse population inclusion, cost-effectiveness analyses, and long-term outcome follow-up in LMIC settings.